A Clear Mandate

      The call on this cold afternoon is for an auto accident in a congested area of the city. The Attack One crew is on scene quickly, and the drivers in the low-speed accident are sitting in their warm vehicles. The driver of the rear vehicle denies injury of any type. There is a young woman in the front vehicle with minor damage to the rear of the car.

   This patient states she is bleeding from her arm and has back pain. She denies neck pain, headache, loss of consciousness and any chest or abdominal pain. Her seat and shoulder belt are in place, as well as a protective pillow she's been sitting on. She says she sliced her arm on a piece of sharp plastic on the storage area between the front seats, and a gaping 6-cm laceration of the right mid-forearm is now just oozing some blood. Neurovascular status in the hand and wrist are completely intact.

   "My young children accidentally broke that storage area jumping between the seats," the woman explains, "and I should have covered it with some tape until I could get it replaced. What am I going to do about my children? I was going to pick them up from school when that lady ran into me. And my back hurts where I had my surgery."

   Crew members elicit the history of a surgery on the woman's sacral area for a cyst she'd had since birth. The surgery was seven days ago, and her surgeon told her it was successful. She had just returned to driving, but had to sit on a pad to avoid discomfort. The pain she's complaining of is the same pain she has any time she sits on the surgical site. She has no other medical problems, and is not taking any blood thinners.

   "Ma'am, that cut on your arm is still oozing blood and is going to need stitches," a crew member tells her. "If your back hurts, we are going to put you on a board and place your neck in a device that will hold it to protect it and your back from any injury. The doctors at the emergency department will check your spine, sew up your arm and make sure your surgical site is OK."

   The young lady immediately resists. "I cannot lie on any kind of board, and really can't lie on my back at all," she says. "I guess I have to get stitches and get my surgical site checked, but you cannot put me on a board. And my neck doesn't hurt at all--why would you put it in something? If I have to get on a board, I will refuse care."

   The Attack One members operate under a spine clearance protocol, and they initiate that process. They perform the necessary history and physical examination to complete the assessment for a possible spine injury, using these decision points:

1. The patient has a history of trauma, but not an obvious high-risk event.
2. The patient is not unconscious and has no altered mental status.
3. The patient has no history of LOC from the trauma event, and no impairment by drugs or alcohol.
4. The patient has no neck/spine pain related to the trauma.
5. The patient has no painful or distracting injuries that would prevent her feeling the pain of a spine injury.
6. The patient has no neck or spine tenderness upon evaluation.
7. There is no spine deformity to palpation.
8. There are no neurologic deficits (weakness, tingling, paralysis).
9. The patient has no pain on movement of the neck or back. As she was talking prior to the crew's arrival, she had been moving her head and neck in all directions, and is actually more comfortable when allowed to move her neck after examination. She then is able to move her neck and back painlessly through a full range of motion.

   Accordingly, the crew transports without spine immobilization and will document the process and findings.

   The crew places the woman in a position of comfort on the stretcher, maintains the bandage on her arm and allows her to use her pillow to make her sacral area more comfortable. She calls the school to arrange for care of her children.